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“... o can prescribe Schedule II drugs under physician delegation?
Can schedule II authority be delegated in a free standing emergency department that is affiliated with a hospital?
How often is physician consultation required when prescribing controlled substances?
Can APRNs and PAs in hospital-ba ... ”
“Online Supervision and Prescriptive Delegation Registration System - Click to access system.
Use the online system to register prescriptive authority AND to file the notice of intent to practice/supervise as required of PAs and physicians. Hard copy supervision and delegation forms are no lon ... ”
“... SUPERVISION & PRESCRIPTIVE DELEGATION REGISTRATION
If you have questions regarding the log in for the Supervision and Prescriptive Delegation Registration System, please use the “HELP” options available in the the upper right hand corner on each screen. ... ”
“...
For additional FAQs on prescriptive delegation, visit: http://www.tmb.state.tx.us/page/prescriptive-delegation
”
“... spital privileges, specialty board certification, delegation information, etc.)and some of which is provided and verified by the board (e.g., license status, educational background, disciplinary actions, etc.):
(1) Full name;(2) Place of birth if the physician requests that it be included in the phy ... ”
“... spital privileges, specialty board certification, delegation information, etc.) and can be updated at any time. Many updates are provided by the physician at a time of licensure renewal/registration. An update may be provided by the licensee between renewals, while certain updates MUST b ... ”
“... tmb.state.tx.us/page/supervision-and-prescriptive-delegation
Limits on Number of Delegates: waived the delegate limit of seven PAs or APRNs that a physician could supervise and delegate to regardless of location or setting.
PITs: allowed Texas hospitals and facilities associ ... ”
“... his time, the Online Supervision and Prescriptive Delegation Registration system is not set up to accept delegation locations outside of Texas.
Any physician, PA or APRN who does not have a TX practice address and needs to register prescriptive delegation, please contact the Registration Department ... ”
Description: Medical Board 2010 - October - Standing Orders Committee Meeting Minutes
Document: ... le action on requests for waivers of prescriptive delegation requirements
The Committee considered six requests for waivers from physicians affiliated with the University of Texas Medical Branch (UTMB) in Galveston. Following discussion, requests from Radoslaw Bukowski, M.D., for an alternate pract ...
Description: Medical Board 2011 - April - Standing Orders Committee Meeting Minutes
Document: ... ction relating to site -specific requirements for delegation of prescriptive authority. After discussion, Ms. Robinson advised that staff would seek stakeholder input regarding several issues: sites that qualify under more than one section of the prescriptive delegation statute, the number of PAs th ...
Description: Medical Board 2011 - August - Standing Orders Committee Meeting Minutes
Document: ... le action on requests for waivers of prescriptive delegation requirements. The committee reviewed a request for waiver of prescriptive delegation requirements from Pilar Bescos, M.D., for an alternate practice site, a site that provides worksite health evaluations for companies in North Texas. Dr. B ...
Description: Medical Board 2011 - August - Licensure Committee - Agenda Item 9: Modifications to Board Rules - 22 TAC 184 - Surgical Assistants
Document: ... assistant's scope of practice is identified; (2) delegation of medical tasks is appropriate to the surgical assistant's level of competence; (3) the relationship between the members of the team is defined; (4) that the relationship of, and access to, the supervising physician is defined; (5) a proc ...
Description: Medical Board 2011 - August - Licensure Committee - Agenda Item 9: Modifications to Board Rules - 22 TAC 192 - Office-Based Anesthesia Services
Document: ... of physicians providing, or overseeing by proper delegation, anesthesia services in outpatient settings and to provide the minimum acceptable standards for the provision of anesthesia services in outpatient settings. (b) The rules promulgated under this title do not apply to physicians who practice ...
Description: Medical Board 2011 - June - Full Board Committee Meeting Minutes
Document: ... mendation, and possible action regarding standing delegation orders for cosmetic procedures that include the use of prescription medications. Ms. Leshikar reported receiving a number of questions regarding who can administer Botox. After discussion, the board set the matter pending for discussion la ...
Description: Medical Board 2011 - November - Licensure Committee Meeting Minutes
Document: ... on, recommendation, and possible action regarding delegation to staff to convert full licenses to administrative medicine licenses for impaired physicians
Licensee #1173 - Ms. Garanflo presented the case of a licensee who reported a physical impairment and requested conversion to an administrative ...
Description: Medical Board 2011 - November - Standing Orders Committee Meeting Minutes
Document: ... le action on requests for waivers of prescriptive delegation requirements. The committee reviewed a request for waiver of prescriptive delegation requirements from Stephen Burns, M.D., for practice in a medically underserved area (MUA) in Paris, Texas. Dr. Burns requests an increase in the number of ...
Description: Medical Board 2012 - April - Standing Orders Committee Meeting Minutes
Document: ... le action on requests for waivers of prescriptive delegation requirements.
Ms Kaufman informed the committee that two applicants had withdrawn their applications upon review by staff that they are in compliance with current prescriptive delegation requirements and do not need waivers at this time.
...
Description: Medical Board 2012 - August -Ad Hoc Retail Clinics Committee
Document: ... elop special requirements related to prescription delegation waiver requests made by physicians that provide supervision and delegate prescription delegation to midlevels that are employed at retail clinics. Dr. Snoots suggested that as the Board considers issues related to prescription delegation, ...
Description: Medical Board 2012 - August - Full Board Committee Meeting Minutes
Document: ... presented oral comments. f. Chapter 193. Standing Delegation Orders. 193.13 Non-Surgical Cosmetic Procedures Ms. Robinson gave a brief summary of proposed amendments to Chapter 193. Standing Delegation Orders. Written comments were received and reviewed. Renee Moschitto, R.N., Suzette Smith, R.N., L ...
Description: Medical Board 2012 - August - Standing Orders Committee Meeting Minutes
Document: ... le action on requests for waivers of prescriptive delegation requirements. The committee reviewed a request for waiver of prescriptive delegation requirements from David Joel Korman, MD for an alternate site in Jacksonville, TX that provides psychiatric services. Dr Snoots moved to grant Dr. Kormans ...
Description: Medical Board 2012 - June - Full board Committee Meeting Minutes
Document: ... th Committee meeting that focused on prescription delegation.
TWC audit. Ms. Robinson reported that the Texas Work Force Commission is in the process of performing an audit at the agency. Outreach Update . Ms. Robinson reported receiving positive responses from county medical societies and medical ...
Description: Medical Board 2012 - June - Standing Orders Committee Meeting Minutes
Document: ... le action on requests for waivers of prescriptive delegation requirements. The committee reviewed a request for waiver of prescriptive delegation requirements from James Christopher Grant, MD for an alternate site in Texas City, TX that provides otolaryngology, ENT allergy and audiology services. Ms ...
Description: Medical Board 2012 - November - Full Board Committee Meeting Minutes
Document: ... ointed as the liaison to the Texas Medical Board. Delegation registration. Ms. Robinson summarized the prescriptive delegation process that was implemented in 2010, requiring physicians to register with the Texas Medical Board if the physician delegates prescriptive authority to PA's or APN's. At th ...
“... eral and state statutes and regulations regarding delegation. The physician retains responsibility of the medical management of the patient. Therefore, the delegating physician must consider the delegatee’s education, training, and experience prior to delegating. Additionally ... ”
When is Physician supervision of a CRNA required?
Regardless of the circumstances when supervision is or is not required, it is important to remember that the delegating physician must abide by all required federal and state statutes and regulations regarding delegation. The physician retains responsibility of the medical management of the patient. Therefore, the delegating physician must consider the delegatee’s education, training, and experience prior to delegating. Additionally, delegation may be revoked by the delegating physician at any time.
The Texas Attorney General has issued three opinions on CRNA supervision. The latest opinion found that although physician supervision of a CRNA is not required in Texas Occupations Code Sec. 157.058, other federal and state statutes and regulations may require physician supervision of a CRNA, a CRNA may not administer an anesthetic that is a controlled substance outside the presence of a physician, and the Legislature did not expressly limit the liability of the delegating physician.
Specifically, Texas Attorney General Opinion KP-0353 found “Section 157.058 of the Occupations Code does not, by itself, require a physician who properly delegates anesthesia-related tasks to a certified registered nurse anesthetist (“CRNA”) to supervise the performance of those acts.” (Page 5)
However, KP-0353 also found “…the language of chapter 157 is not the only relevant authority to consider in addressing the question of physician supervision over acts delegated to a CRNA. Federal regulations limiting Medicare coverage and conditioning hospital participation in Medicare and Medicaid programs require physician supervision of a CRNA when administering anesthesia in certain circumstances. See, e.g., 42 C.F.R. §§ 416.42(b)(2), 482.52(a)(4), 485.639(c)(1)(v), (2) (requiring a CRNA to operate under a physician’s supervision when administering anesthesia in certain circumstances). Furthermore, a CRNA may not administer an anesthetic that is a controlled substance outside the presence of a physician. See TEX. HEALTH & SAFETY CODE §§ 481.002(1)(A) (defining “administer” to require agent to apply controlled substance in presence of physician), .071(a) (prohibiting physician from causing controlled substance to be administered under physician’s “direction and supervision” except for valid medical purpose and in course of medical practice). And a CRNA may not obtain an anesthetic that is a dangerous drug unless a physician has listed that CRNA as the physician’s designated agent. See id. §§ 483.001(4) (defining “designated agent”), .022(a) (requiring physician to name each designated agent in writing). (Page 3 with emphasis added.)
Finally, KP-0353 found “Whether and the extent to which physician supervision is required for an act delegated to a CRNA will depend on the specific act delegated, the type of facility in which the CRNA performs the act, and any relevant regulations of that facility. And while section 157.058 authorizes a physician to delegate to a CRNA, a physician is never required to do so. If a physician is concerned about a CRNA’s ability to perform a delegated act or desires to limit the delegation, the physician retains the authority to refrain from delegating, to limit the delegation, or to supervise the delegation to whatever extent the physician determines necessary. In sum, the authority to delegate provided by section 157.058 of the Occupations Code does not eliminate the need to comply with all other applicable statutes, regulations, bylaws, ethical standards, and a physician’s own professional judgment. See TEX. OCC. CODE § 157.007 (“An act delegated by a physician under [chapter 157] must comply with other applicable laws.”). (Page 4 with emphasis added.)
“APRNs or PAs may prescribe schedule II drugs in the following situations: (1) in a hospital facility-based practice, in accordance with policies approved by the hospital's medical staff or a committee of the hospital's medical staff as provided by the hospital's bylaws to ensure patient safety ... ”
Who can prescribe Schedule II drugs under physician delegation?
APRNs or PAs may prescribe schedule II drugs in the following situations:
(1) in a hospital facility-based practice, in accordance with policies approved by the hospital's medical staff or a committee of the hospital's medical staff as provided by the hospital's bylaws to ensure patient safety and as part of care provided to a patient who:
(A) has been admitted to the hospital for an intended length of stay of 24 hours or greater; or
(B) is receiving services in the emergency department of the hospital; or
(2) as part of the plan of care for the treatment of a person who has executed a written certification of a terminal illness, has elected to receive hospice care, and is receiving hospice treatment from a qualified hospice provider.
“... pital anddoes not qualify as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be ... ”
Can schedule II authority be delegated in a free standing emergency department that is affiliated with a hospital?
No. A free standing emergency department is not located within the hospital anddoes not qualify as an eligible site for delegation of schedule II authority. The physician may only delegate authority to prescribe controlled substances in schedules III through V in this setting. Authority to prescribe dangerous drugs, nonprescription drugs and devices may be delegated in any setting.
“Yes. Nothing changed for delegation of prescriptive authority for controlled substances in schedules III through V. ”
Can APRNs and PAs in hospital-based clinics continue to prescribe drugs in schedules III through V?
Yes. Nothing changed for delegation of prescriptive authority for controlled substances in schedules III through V.
“... ian who may be subject to discipline for improper delegation dependent upon the facts and circumstances of each case, and how state statutes and regulations apply in those situations. ”
Is a CRNA under a valid delegation order, subject to discipline by the Texas Medical Board under the Medical Practice Act for a violation of the standard of care in the selection and administration of anesthesia or the care of an anesthetized patient?
No, while the selection and administration of anesthesia is a medical act, if such an act was validly delegated to a CNRA by a physician, the act is considered to be within the practice of nursing and governed by the Nursing Practice Act. Any discipline for a violation of the standard of care by a CRNA would be carried out by the Texas Board of Nursing under the authority of the Nursing Practice Act. Ultimate responsibility and accountability for the medical management of a patient under anesthesia remains with the delegating physician who may be subject to discipline for improper delegation dependent upon the facts and circumstances of each case, and how state statutes and regulations apply in those situations.
“... endent authority to administer anesthesia without delegation by a physician.” (Page 5). Since the selection and administration of anesthesia is a medical act, CRNAs must be properly delegated this act by a physician. A CRNA who administers anesthesia without proper delegation from a ... ”
Are CRNA’s authorized to practice independent of physician supervision and delegation?
No, neither the Medical Practice Act nor the Nursing Practice Act authorize independent practice by a CRNA. Additionally, Texas Attorney General Opinion No. KP-0266 found “A certified registered nurse anesthetist does not possess independent authority to administer anesthesia without delegation by a physician.” (Page 5). Since the selection and administration of anesthesia is a medical act, CRNAs must be properly delegated this act by a physician. A CRNA who administers anesthesia without proper delegation from a physician would be liable for the unlicensed practice of medicine.
“... m. If there is a change to the scope of the delegation, physicians must notify the Board within 30 days of this change.PAs are likewise required to register their supervising physicians with the Board prior to beginning to practice under the employment or prescriptive authority agreement. ... ”
Do I have to let the Medical Board know about my delegates/supervising physicians?
Yes, if you are a physician or a physician assistant.
Physicians are required to register all PAs and APRNs that they supervise prior to the delegates beginning to work for them. If there is a change to the scope of the delegation, physicians must notify the Board within 30 days of this change.
PAs are likewise required to register their supervising physicians with the Board prior to beginning to practice under the employment or prescriptive authority agreement. They are also required to notify the Board within 30 days of any change to the scope of the delegation.
APRNs should look to guidance provided by the Texas Board of Nursing for how to register their delegating physicians, as the Medical Board does not have licensing authority for nurses.